Prolongiertes Weaning^[*]

 

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Zusammenfassung

Beatmungstherapie stellt einen zentralen und wesentlichen Bestandteil der modernen Intensivmedizin dar. Sie kommt bei Patienten mit schwerer respiratorischer Insuffizienz infolge Versagens der muskulären Atempumpe oder eines Oxygenierungsversagens bei direkter oder indirekter Schädigung des Lungenparenchyms zum Einsatz, wenn mit anderen Maßnahmen (Sauerstoffgabe, Lagerungstherapie, Sekretmanagement oder kontinuierlichem positivem Atemwegsdruck – Continuous Positive Airway Pressure [CPAP]) keine ausreichende Stabilisierung erreicht werden kann.

Während der Beatmungszeit wird die Ursache der Atmungsinsuffizenz behandelt. Es entfallen ungefähr 40 – 50 % der gesamten Beatmungszeit eines Intensivpatienten auf die Entwöhnung von der maschinellen Beatmung (Weaning).

Der überwiegende Anteil beatmeter Patienten kann nach kurzzeitiger Beatmungstherapie unproblematisch von der Beatmung entwöhnt werden. Allerdings muss eine Beatmung bei ca. 20 % der Patienten auch noch dann fortgesetzt werden, wenn die ursprüngliche Indikation (z. B. eine schwere Pneumonie) längst behoben ist, sodass die Phase des Weanings deutlich verlängert ist. Neben der respiratorischen Funktionsstörung tragen häufig hohes Alter und Komorbiditäten der Patienten zum prolongierten Weaningprozess bei.

Nach internationalem Konsens liegt ein prolongiertes Weaning dann vor, wenn es erst nach drei erfolglosen Spontanatmungsversuchen (Spontaneous Breathing Trial = SBT) oder nach über sieben Tagen Beatmung nach dem ersten erfolglosen SBT gelingt.

Das Patientenkollektiv mit prolongiertem Weaning stellt das behandelnde Team vor eine besondere Herausforderung. Ganz wesentlich für den Therapieerfolg ist die eng verzahnte interdisziplinäre Versorgung der prolongiert beatmeten Patienten. Nicht selten sind es der fehlende multidisziplinäre Ansatz und die unzureichende Beachtung der multifaktoriellen Ursachen, die ein erfolgreiches Weaning verhindern. Das erfolgreiche Weaning dieser Patienten setzt eine hohe Expertise in der modernen Intensivmedizin, der Anwendung invasiver und nicht-invasiver Beatmungsverfahren, klare Weaningkonzepte sowie eine enge, fachübergreifende inderdisziplinäre Absprache voraus.

Bei sehr komplexem prolongierten Weaningprozess gelingt es in spezialisierten Weaningzentren/-einheiten in ca. 50 % der Fälle, doch noch ein Weaningversagen abzuwenden.

Bei einem Teil der Patienten schlagen auch wiederholte Weaningversuche fehl, sodass gegebenenfalls eine dauerhafte Beatmung in außerklinischer Umgebung erforderlich ist.

Aufgrund der wachsenden Bedeutung des prolongierten Weanings wurde diese Leitlinie auf Initiative der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP) gemeinsam mit anderen wissenschaftlichen Gesellschaften, die sich zum Thema prolongiertes Weaning engagieren, entwickelt.

Es liegt der Leitlinie eine systematische Recherche von Leitliniendatenbanken, Cochrane Library und PubMed zugrunde.

Unter der Moderation der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) erfolgte die Konsensusfindung im formalen interdisziplinären Verfahren mittels nominalem Gruppenprozess (Delphi-Verfahren).

In der Leitlinie werden Definitionen, Epidemiologie und Weaningkategorien, die zugrundeliegende Pathophysiologie, das gesamte Spektrum der verfügbaren Therapiestrategien, die Weaningeinheit, die Überleitung in eine außerklinische Beatmung und schließlich Empfehlungen zu Therapieentscheidungen am Ende des Lebens bei prolongiertem bzw. erfolglosem Weaning abgehandelt. Die Besonderheiten bei pädiatrischen Patienten werden innerhalb der einzelnen Kapitel jeweils gesondert behandelt.

Adressaten der Leitlinie sind Intensivmediziner, Pneumologen, Anästhesisten, Internisten, Kardiologen, Chirurgen, Neurologen, Pädiater, Geriater, Palliativmediziner, Pflegekräfte, Physiotherapeuten, Atmungstherapeuten, der Medizinische Dienst der Krankenkassen (MDK), der Medizinische Dienst des Spitzenverbandes Bund der Krankenkassen e. V. (MDS) und die Hersteller von Beatmungstechnik.

Das wesentliche Ziel dieser Leitlinie ist es, den aktuellen Wissensstand zum Thema „Prolongiertes Weaning“ in der Akutmedizin primär auf der Basis der Erfahrung von Experten bei noch fehlenden wissenschaftlichen Daten zu etablieren.

Abstract

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by insufficiency of the respiratory muscles and/or lung parenchymal disease when/after other treatments, i. e. oxygen, body position, secretion management, medication or non invasive ventilation have failed.

In the majority of ICU patients weaning is routine and does not present any problems. Nevertheless 40–50 % of the time during mechanical ventilation is spent on weaning. About 20 % of patients need continued MV despite resolution of the conditions which originally precipitated the need for MV.

There maybe a combination of reasons; chronic lung disease, comorbidities, age and conditions acquired in ICU (critical care neuromyopathy, psychological problems).

According to an International Consensus Conference the criteria for “prolonged weaning” are fulfilled if patients fail at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial.

Prolonged weaning is a challenge. An inter- and multi-disciplinary approach is essential for weaning success.

Complex, difficult to wean patients who fulfill the criteria for “prolonged weaning” can still be successfully weaned in specialised weaning units in about 50% of cases.

In patients with unsuccessful weaning, invasive mechanical ventilation has to be arranged either at home or in a long term care facility.

This S2-guideline was developed because of the growing number of patients requiring prolonged weaning. It is an initiative of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP) in cooperation with other societies engaged in the field.

The guideline is based on a systematic literature review of other guidelines, the Cochrane Library and PubMed.

The consensus project was chaired by the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) based on a formal interdisciplinary process applying the Delphi-concept.

The guideline covers the following topics: Definitions, epidemiology, weaning categories, pathophysiology, the spectrum of treatment strategies, the weaning unit, discharge from hospital on MV and recommendations for end of life decisions. Special issues relating to paediatric patients were considered at the end of each chapter.

The target audience for this guideline are intensivists, pneumologists, anesthesiologists, internists, cardiologists, surgeons, neurologists, pediatricians, geriatricians, palliative care clinicians, nurses, physiotherapists, respiratory therapists, ventilator manufacturers.

The aim of the guideline is to disseminate current knowledge about prolonged weaning to all interested parties. Because there is a lack of clinical research data in this field the guideline is mainly based on expert opinion.

^* Weitere beteiligte Wissenschaftliche Fachgesellschaften und Institutionen:
Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V. (DGAI)
Deutsche Gesellschaft für Chirurgie (DGCH)
Deutsche Gesellschaft für Ernährungsmedizin e. V. (DGEM)
Deutsche Gesellschaft für Fachkrankenpflege und Funktionsdienste e. V. (DGF)
Deutsche Gesellschaft für Geriatrie e. V. (DGG)
Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin e. V. (DGIIN)
Deutsche Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e. V. (DGK)
Deutsche Gesellschaft für Neurointensiv- und Notfallmedizin e. V. (DGNI)
Deutsche Gesellschaft für Palliativmedizin e. V. (DGP)
Deutsche Interdisziplinäre Gesellschaft für Außerklinische Beatmung e. V. (DIGAB)
Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin (DIVI)
Deutscher Industrieverband für optische, medizinische und mechatronische Technologien e. V. (SPECTARIS)
Deutscher Verband für Physiotherapie (ZVK) e. V.
Deutschsprachige Medizinische Gesellschaft für Paraplegie e. V. (DMGP)
Gesellschaft für Neonatologie und Pädiatrische Intensivmedizin (GNPI)

¹ Sprecher

² Personalunion: Kernredaktion und AG-Sprecher

³ AG-Sprecher in alphabetischer Reihenfolge

⁴ AWMF
(die übrigen Teilnehmer der Konsensuskonferenzen werden S. 23–27 aufgeführt)

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